HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure all smoke barriers were maintained as a continuous membrane in 3 of 6 smoke compartments. The findings were:

Observation on 8/11/10 between 8:30 AM and 4:00 PM revealed the following concerns:
1. A 2 sq. ft. ceiling tile was missing in the social services' office.
2. There was a 4-inch hole in the ceiling of the laboratory wash room.
3. There was a 1.5-inch hole in the ceiling of the newborn nursery fetal-monitoring room.
4.There were multiple gaps (approximately 15) in the ceiling of electrical room #3, through which electrical conduit was passing.
5. There was 2-inch triangular piece of ceiling tile missing in the room where the sitz bath was located.
6.There was an 18-inch triangular piece missing in the ceiling of the housekeeping closet storage room.

The director of plant operations verified the above findings at the time of the observations.

Based on observation and staff interview, the facility failed to ensure 4 corridor doors were resistant to the passage of smoke in 2 of 6 smoke compartments. The findings were:

Observation on 8/11/10 between 8:30 AM and 4 PM revealed the following concerns:
1. The corridor doors to patient room #133 and the library room door across from the nurses' station did not close completely in their respective frames unless force in excess of 5 foot pounds of pressure was applied.
2. One door leading into the accounting office did not closed completely in its frame with three separate attempts. A self closure device was attached to the door. In addition, the other door leading into the accounting office also did not close in its frame due to the recent installation of new carpeting preventing the door from swinging freely.

The director of plant operations verified the above findings at the time of the observations.

Based on observation and staff interview, the facility failed to ensure 2 hazardous areas were separated from patient use areas in 2 of 6 smoke compartments. The findings were:

Observation on 8/11/10 between 9 AM and 4 PM revealed the soiled utility room door in the newborn nursery and the housekeeping closet door across from the nurses' station door did not securely latch into their frames with three separate attempts. Each door had a self closure device. In addition, the door to the medical records storeroom did not have a self closure device attached.

The director of plant operations verified the above findings at the time of the observations.

Based on observation and staff interview, the facility failed to ensure the fire suppression (sprinkler) system was properly maintained. The findings were:

Observation on 8/11/10 between 9 AM and 4 PM revealed a gap greater than 1/2-inch existed between the sprinkler head escutcheons and the ceiling in the sitz bath and in the ethylene oxide mechanical room. In addition, a sprinkler head was observed to be recessed into the ceiling in the operating room storage closet. Finally, observation at 2:48 PM revealed the mechanical room lacked adequate numbers and types of spare sprinkler heads in the storage cabinet. The director of plant operations verified the above findings at the time of the observations.

Based on observation and staff interview the facility failed to ensure the electrical system was maintained as required by code in 3 of 6 smoke compartments. The findings were:

Observation on 8/11/10 between 9 AM and 4 PM revealed the following concerns:
1. A three way electrical plug adaptor was plugged into a wall outlet under the nurse's station. Three office appliances were plugged into the adaptor.
2. An extension cord was plugged into a surge protector in the resource manager's office. Plugged into the extension cord was a microwave oven. In addition, an extention cord was being used in the human resources office. Several office equipment machines were plugged into the extension cord.
3. Two data cover plates were not attached to the wall in the CNO's office or in the pharmacy room.
4. Electrical panels were blocked by a medical cart at the end of the hall in the obstetrics department and by a film cart in the nuclear medicine department.

The director of plant operations verified the above findings at the time of the observations.

Based on observation and staff interview, the facility failed to ensure all smoke barriers were maintained as a continuous membrane in 3 of 6 smoke compartments. The findings were:

Observation on 8/11/10 between 8:30 AM and 4:00 PM revealed the following concerns:
1. A 2 sq. ft. ceiling tile was missing in the social services' office.
2. There was a 4-inch hole in the ceiling of the laboratory wash room.
3. There was a 1.5-inch hole in the ceiling of the newborn nursery fetal-monitoring room.
4.There were multiple gaps (approximately 15) in the ceiling of electrical room #3, through which electrical conduit was passing.
5. There was 2-inch triangular piece of ceiling tile missing in the room where the sitz bath was located.
6.There was an 18-inch triangular piece missing in the ceiling of the housekeeping closet storage room.

The director of plant operations verified the above findings at the time of the observations.

Based on observation and staff interview, the facility failed to ensure 4 corridor doors were resistant to the passage of smoke in 2 of 6 smoke compartments. The findings were:

Observation on 8/11/10 between 8:30 AM and 4 PM revealed the following concerns:
1. The corridor doors to patient room #133 and the library room door across from the nurses' station did not close completely in their respective frames unless force in excess of 5 foot pounds of pressure was applied.
2. One door leading into the accounting office did not closed completely in its frame with three separate attempts. A self closure device was attached to the door. In addition, the other door leading into the accounting office also did not close in its frame due to the recent installation of new carpeting preventing the door from swinging freely.

The director of plant operations verified the above findings at the time of the observations.

Based on observation and staff interview, the facility failed to ensure 2 hazardous areas were separated from patient use areas in 2 of 6 smoke compartments. The findings were:

Observation on 8/11/10 between 9 AM and 4 PM revealed the soiled utility room door in the newborn nursery and the housekeeping closet door across from the nurses' station door did not securely latch into their frames with three separate attempts. Each door had a self closure device. In addition, the door to the medical records storeroom did not have a self closure device attached.

The director of plant operations verified the above findings at the time of the observations.

Based on observation and staff interview, the facility failed to ensure the fire suppression (sprinkler) system was properly maintained. The findings were:

Observation on 8/11/10 between 9 AM and 4 PM revealed a gap greater than 1/2-inch existed between the sprinkler head escutcheons and the ceiling in the sitz bath and in the ethylene oxide mechanical room. In addition, a sprinkler head was observed to be recessed into the ceiling in the operating room storage closet. Finally, observation at 2:48 PM revealed the mechanical room lacked adequate numbers and types of spare sprinkler heads in the storage cabinet. The director of plant operations verified the above findings at the time of the observations.

Based on observation and staff interview the facility failed to ensure the electrical system was maintained as required by code in 3 of 6 smoke compartments. The findings were:

Observation on 8/11/10 between 9 AM and 4 PM revealed the following concerns:
1. A three way electrical plug adaptor was plugged into a wall outlet under the nurse's station. Three office appliances were plugged into the adaptor.
2. An extension cord was plugged into a surge protector in the resource manager's office. Plugged into the extension cord was a microwave oven. In addition, an extention cord was being used in the human resources office. Several office equipment machines were plugged into the extension cord.
3. Two data cover plates were not attached to the wall in the CNO's office or in the pharmacy room.
4. Electrical panels were blocked by a medical cart at the end of the hall in the obstetrics department and by a film cart in the nuclear medicine department.

The director of plant operations verified the above findings at the time of the observations.